Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.67% due to errors involving two residents. The first incident involved a resident with a history of Type 2 diabetes mellitus, chronic kidney disease, and other health issues. The resident was prescribed insulin lispro, which was not administered correctly by an LVN who failed to prime the insulin pen before injection. The LVN admitted to not having received training on the use of insulin pens and was unaware of the need to prime them before administration. The Director of Nursing (DON) acknowledged the lack of training and the absence of a specific policy for insulin pen administration. The second incident involved a resident with dementia and chronic pain, who was prescribed polyethylene glycol 3350 for bowel management. An MA administered only half the prescribed dose by filling the cap to the wrong line, resulting in an incomplete dose. The MA believed she had filled the cap correctly but later acknowledged the mistake. The DON noted that aides could use a graduated cup for accurate measurement and emphasized the importance of administering the full dose for the medication's intended effect. The facility's policy on medication administration, revised in 2019, requires medications to be administered safely, timely, and as prescribed. However, the lack of adherence to this policy and the absence of specific training and guidelines for insulin pen use contributed to the medication errors. Manufacturer instructions for insulin lispro emphasize the importance of priming the pen to ensure correct dosing, which was not followed in this case.